This is my authorization to release my health information to:
As the patient/legal guardian signing this authorization, I understand that I am giving my permission for my confidential health information to be released by Piedmont Eye Center, Inc., to the recipient(s) specified above. The health information will be released to the recipient by fax when a fax number is provided. If no fax number is provided the records will be mailed to the address listed above unless other arrangements are specified. Once the health information is released by Piedmont Eye Center, this authorization will expire.
*Note: Once the release has been requested, please allow 10-14 business days for the records to be processed. This transaction may be subject to a monetary fee depending on the number of pages being processed.